ORAL HABITSDefinitions 1. According to Boucher O.C. Habit is a tendency towards an act or an act that has become repeated performance, relatively fixed, consistent, easy to performed and almost automatic. 2. According to Dorland(1957) Habit is a fixed or a constant practice established by frequent repetition. 3. According to Buttersworth(1961) Frequent or constant practice or acquired tendency, which has been fixed by frequent repetition. 4. According to Matthewson(1982) Oral habits are learned pattern of muscular contractions. Classifications 1. Based on their causative factors Obsessive ( deep rooted) Non Obsessive ( easily learned and dropped) Intentional / meaningful ( nail biting, digit sucking, lip biting) masochistic / selft inflicting injurious habit ( gingival stripping) unintentional / empty ( abnormal pillowing, chin propping) functional habits ( mouth breathing, tongue thrusthing, bruxism) 2. Based on author a. James (1923) Useful habits – habits of normal function, eg. correct tongue position, proper respiration and deglutition Harmful habits – those exert perverted stress against the teeth and dental arches, eg. Mouth breathing, tongue thrusting 1 b. Kingsley (1958) Functional oral habits Muscular habits Combined ones c. Morris and Bohanna (1969) Non pressure habits – mouth breathing Pressure habits – sucking habit : lip sucking, thumb and digit sucking biting habit: nail biting/ needle holding Postural habit – pillow rest, chin rest Miscellaneous habit – bruxism d. Klein (1971) Empty habits – meaningless habit Meaningful habits – deep rooted psychological problem e. Finn (1987) Compulsive ( when security is threatened) / non – compulsive habits (continuing behavior modification) Primary / secondary habits ( habit that is due to supplemental problem) Thumb Sucking Definition Thumb sucking may be defined as placement of thumb into various depths in the mouth. Classification 1. Based on clinical observation a. Normal thumb sucking – during first and second year of life; disappear as the child matures b. Abnormal thumb sucking - persists beyond the preschool period Psychological : deep rooted emotional factor; may assc with insecurities, neglect or loneliness Habitual 2. Based on O’ Brien 1996 2 Non nutritive sucking stems from an adaptive response b.a. Oral drive theory ( Sears and Wise 1982) a. while at the same time maxillary and mandibular anteriors contact is present b. bottle feeding b. thumb is placed into the oral cavity without touching the vault of the palate. Nutritive – breast feeding. but there is no contact with the mandibular incisor d. contacting the hard palate and only the maxillary incisors. Subtelny (1973) a. Prolong nursing cause thumb sucking pleasurable feeling 3 . Johnson (1993) Level Level I (+/-) Level II (+/-) Level III (+/-) Level IV (+/-) Level V (+/-) Level VI (+/-) Description Boys or girls of any chronological age with a habit that occurs during sleep Boys below age 8 with a habit that occurs at one setting during waking hours Boys under age 8 years with a habit that occurs at multiple setting during waking hours Girls below age 8 or a boy over 8 years with a habit that occurs at one setting during waking hours Girls under age 8 years or a boy over 8 years with a habit that occurs across multiple setting during waking hours Girls over age 8 years with a habit during waking hours (+/-) designated willingness of the parents to participate in treatment Theories 1. Type B: 13 – 24%. very little portion of the thumb is placed into the mouth 4. The learning theory ( Davidson 1967) a. while at the same time maxillary and mandibular anteriors contact is maintained. Type D: 6%. Strength of the oral drive is in part a function of how long a child continued to feed by sucking b. Child takes everything and anything to the oral cavity 2. c. the thumb is placed into the mouth just beyond the first joint. whole digit is placed inside the mouth with the pad of the thumb pressing over the palate. Psychoanalytic theory ( oral phase) b. Classical Freudian theory ( 1905) a. Type A: 50%. Infant assc sucking with such pleasurable feeling 3. Non – nutritive sucking habit ( NNS habit): thumb/ finger/ pacifier sucking 3. Type C: 18%. Order of birth of the child: later sibling ranks. Parent’s occupation/ socioeconomic status: low socioeconomic status. Sucking reflex ( Ergel 1962): 1st coordinated muscular activity of the infant Maintenance of the habit thumb sucking habit cease by the age of 3 . increase the attention meted out 4. Age of the child: a. Social adjustment and stress 6. Neonates: insecurities related to primitive demand as hunger 4 infant suckles intensively for long time exhausting the .4. greater chance of habit 5. mother unable to provide sufficient breast milk sucking urge 2. Feeding practice: more in breast feed children. Johnson and Larson ( 1993): Psychoanalytic and learning theories explains that children posses an inherent biologic drive for sucking 5. Rooting reflex ( Benjamin 1962): Movement of the infant’s head and tongue towards an objects touching its cheek 6. abrupt weaning contribute to acquiring an oral habit 7. Working mother: children develop feeling of insecurity 3. of sibling: more the no. No.4 years acute increase stress/ anciety due to underlying psychological/ emotional disturbance conversion of an empty habit into meaningful stress reduction response Etiological factor 1. Increase overjet b. Atypical root resorption in primary central incisor g. Hypotonic upper lip d. require psychological therapy and an integrated approach by the dentist 5 III Teenage child . Lower tongue position c. Anterior open bite 4. Effects on mandible: a.b. Anterior placement of the apical base of the maxilla d. Decrease oberbite c. Retrusion of mandible 3. Proclination of the maxillary incisors b. Development of tongue thrust b. Posterior cross bite d. 1st week of life: related to feeding problems c. clinically significant anxiety. Effects on maxilla: a. Increase maxillary arch length c. Hyperactive lower lip Phase I II Clinical stage Normal/ sub clinically significant sucking Clinically significant sucking Intractable sucking Age of child Preschool infant Grade school Inference From children to about 3 years at the time of weaning 3 – 6 years. During eruption of primary teeth: relieve teething Clinical findings 1. Retroclination of mandibular incisors b. High palatal arch f. Constriction of maxillary arch 2. Effects on lip placement and function a. Effects on interarch relationship a. Increase trauma to maxillary incisors h. it is the time to solve dental problems related to digit sucking After the child 4th year. Increase clinical crown length of maxillary incisor e. Dentoalveolar structures: Flared and proclined max. Motivation of the child to stop the habit 4. Malocclusion produced depends on: a. Psychological status of the child 2. chapped and short finger nail Fibrous roughed callous present on the superior aspect of the finger c. Extraoral examination: a. narrow palate Management A. Parental concern regarding the habit 6 . Position of the digit b. Emotional status 3. exceptionally clean. Facial skeletal pattern e. Age factor 3. Intaoral examination a.5. Facial profile: convex d. action during swallowing b. frequency and duration of force applied Diagnosis 1. Digits: b. enlarged tonsil 4. Others: buccal cross bite. History 2. Tongue: size and position at rest. Mandibular position during sucking d. Lips: Short and hypotonic upper lip Hyperactive lower lips proclination of upper anterior teeth Red. Others: middle ear infection. Intensity. anteriors Diastema Retroclined mandibular anteriors c. Treatment considerations 1. Assc orofacial muscle contractions c. pepper and castor oil E. Chemical treatment 1. frightening 3. Quinine. Avoid nagging. Bitter and sour chemicals. Mother’s presence and attention during bottle feeding 6. anatomic variation in the perioral soft tissue and present of other habit B. Parents involvement in prevention: parent advise to spend time with the child so as to put away his feeling of insecurity 4. Psychological therapy 1. Motive based approach 2. Reminder therapy 1. Extraoral approaches: Ace bandage approach: nightly use of an elastic bandage wrapped across the elbow Use of long sleeve nightgown: interfere with the contact of the thumb and oral cavity Thumb home concept: small bag is given to the child to tie around his wrist during sleep Hand puppet Thumb sucking book 7 psychological dependence is suspected .5. Use of a dummy/ pacifier C. Positive behavior modification techniques and hypnosis 6. Dunlops’s β hypothesis = if a subjects forced to concentrate on the performance of the act at the time he practices it. scolding. eg. Constant reassurances and encouragement 5. Screen for underlying psychological disturbances referred to professional for counseling 2. D. Adequate emotional support 4. Child’s engagement in various activities 3. Preventive treatment 1. Use of physiological nipple 7. Duration of breast feeding: duration should adequate to exhaust children’s sucking urge and feel completely satisfied 5. Other factors: malocclusion. he could learn to stop performing the act. palatal arch. According to Braver(1965) A tongue thrust was said to be present if tongue was observed thrusting between. 3. Intraoral approaches: Removable appliances: palatal crib. lingual spurs. rakes. Hay rake 4. Tongue Thrusting Definitions 1. Removable or fixed palatal crib: Break the suction force Remind the patient of his habit Make the habit a non pleasurable one 2. Quad helix – expand the constricted maxillary arch 6. Mechanical therapy 1. Blue grass appliance: Teflon roller 5. 2. so that tongue becomes interdental. Oral screen: Redirecting the pressure of the muscular and soft tissue curtain of the cheeks and lips Prevents placing the thumb or finger into the oral cavity during sleeping hours 3. According to Barber(1975) 8 . and the teeth didn’t close in centric occlusion during deglutition. Modified blue grass appliance: 2 rollers of different colour and material. suction will not be created. My special shirt 2. thumb is slip from the rollers thus breaking the act. Hawley’s retainer with/ without spurs Fixed appliances: upper lingual tongue screen F. According to Tulley(1969) States tongue thrust as forward movement of tongue tip between teeth to meet lower lip during deglutition and in sounds of speech. Physiologic: comprises of normal tongue thrust swallow of infancy. it can be grouped as functional. According to Schneider(1982) Tongue thrust is a forward placement of tongue between anterior teeth and against lower lip during swallowing Classification 1. 2. Moyer’s classification of swallowing patterns Type Normal infantile swallow Inference Tongue lies in btw gum pads and mandible Disappears on eruption of the buccal teeth of primary dentition During primary dentition and early mixed dentition period Very little lip and cheek activity Contraction of the lips. Habitual: tongue thrust swallow is present as a habit even after correction of malocclusion. Classification of James S Brauer and Townsend V Holt classification of tongue thrusting Type 1 2 Clinical presentation Non deforming tongue thrust Deforming anterior tongue thrust Subgroup 1: anterior open bite Subgroup 2: assc procumbency of anterior teeth Subgroup 3: assc posterior cross bite Deforming lateral tongue thrust Subgroup 1: posterior open bite Subgroup 2: posterior cross bite Subgroup 3: deep overbite Deforming anterior and lateral tongue thrust Subgroup 1: anterior and posterior open bite Subgroup 2: assoc procumbency of anterior teeth Subgroup 3: associated with posterior cross bite 3 4 6. mentalis muscle and mandibular elevators. 3.Tongue thrust is an oral habit pattern related to persistence of an infantile swallow pattern during childhood and adolescence and thereby produces an open bite and protrusion of anterior tooth segments. 4. Anatomic: person having enlarged tongue can have an anterior tongue posture 5. 4. Functional: when tongue thrust mechanism is an adaptive behavior developed to achieve an oral seal. Teeth apart swallow 9 Transitional swallow Normal mature swallow Simple tongue thrust swallow Complex tongue thrust swallow . Allergies 12. Feeding practices and tongue thrusting 6. Intraoral findings 1. Mandibular movements: more erratic. Functional adaptability to transient change in anatomy 5. Neurologic disturbances 4. Extraoral finding 1. Facial form: increase anterior facial height. Tongue movement: tongue tip at rest is lower 2. no correlations found btw the movements of the tongue tip and the mandibular Mandibular movement is upward and backward with the tongue move forward 3. Other oral habits – thumb sucking 7. Hereditary 8. facial and mentalis muscles but absence of temporal muscle contraction Etiology 1. Upper respiratory tract infection 3. Oral trauma 14. Malocclusion: a. Sleeping habits Clinical features A. Tongue size . Mixed dentition 10. Speech disorder 4. Features pertaining to the maxilla: 10 .macroglossia/ microglossia 9. B. Lip posture: lack of compensatory lip activity 2.Marked constriction of the lip. Retained infantile swallow 2. Soft diet 13. Gap filling tendency 11. Functional examination: a. proclination of maxillary anteriors resulting in an increase in overjet generalized spacing btw the teeth maxillary constriction b. contraction of the lips. Observe the tongue during: Conscious swallow Command swallow of saliva Command swallow of water Conscious swallow during mastication 4. normal tooth contact in posterior region b. Lateral tongue thrust a. History 2. generalized open bite b. Place water beneath tongue tip and swallow: Normal: mandible rises and teeth are brought together but no contraction of lips or facial muscles 11 . Intermaxillary relationship anterior or posterior open bite posterior teeth cross bite 3. anterior open bite c. Posterior open bite with lateral tongue thrust Diagnosis 1. Examination of tongue: size. Palpatory examination: a. Observe the tongue position in rest position b. absence of contracture of lip and oral muscles 5. Complex tongue thrusting a. Features pertaining to the mandible: retrocline or proclination of mandibular teeth c. Simple tongue thrusthing: a. shape and movements 3. mentalis muscle and mandibular elevators 4. Age 2. Hold the lower lip and swallow: Normal: swallow complete Tongue thrusting: cant complete swallow Treatment 1. Tongue thrusting: marked contraction of lips and facial muscles b. Presence/ absence of assc manifestation 3. Subconscious therapy – patient give self instruction Treatment consideration 1. gargling. Place hand over temporalis muscle and swallow : Normal: temporalis contracts and mandible is elevated Tongue thrusting: no temporalis contraction c. yawning 2. squeezing and swallow Lip exercise – tug of war and button pull exercise Other exercises: whistling. Malocclusion 4. Associated with other habit 12 . reciting the count from 60 – 69. Myofunctional exercises Place tongue tip in the rugae for 5 minutes and ask to swallow Orthodontic elastic and sugarless fruit drop held by tongue tip against the palate on the rugae 4S exercise . salivation. Mechano – therapy Preorthodontic trainer for myofunctional training – correct positioning the tongue with tongue tags Nance palatal arch appliance – acrylic button used as a guide to place tongue in the correct position Modifications of Hawley’s appliance Tongue crib Oral screen 3. Speech defects 5.spot. Mouth Breathing Definitions 1. Developmental and morphologic anomalies of nasal cavity. Infection and inflammation of nasal mucosa Clinical Features 1. According to Merle(1980). turbinates 11. Traumatic injuries to the nasal cavity 12. c. Abnormally short upper lip preventing proper lip seal 6.suggested the term oro-nasal breathing instead of mouth breathing Classifications 1. 2. Obstructive: children who have increased resistance or a complete obstruction of normal flow of air in nasal passages. Habitual: child continually breathes through the mouth by force of habit although abnormal obstruction has been removed Etiology 1. Genetic pattern: ectomorphic children of tapering face 13. According to Sassouni (1971)-Habitual respiration through mouth instead of nose. Child is forced to breathe through the mouth. Anatomic: anatomic mouth breather is one short upper lip doesn’t permit complete closure without undue effort. Child bends the neck forward straightening the oro – naso – pharyngeal path 13 . Thumb sucking or similar oral habits 9. b. Obstruction in bronchial tree or larynx 7. General effects: a. Allergic rhinitis. Deviated septum and other naso-pharyngeal abnormalities 3. Enlarged turbinates 2. Genetically predisposing factors 10. According to Finn (1987) a. Obstructive sleep apnea syndrome 8. nasal polyp. 4. Enlarged adenoid or tonsils 5. Sleep apnea syndrome – loss of cleansing action of saliva partial or complete obstruction of the oro pharynx during sleep 2. Appearance a. Short upper lip e. dental effects: Protrusion of maxillary and mandibular incisors Narrow maxillary arch High palatal vault Anterior open bite Mandible hangs open in a slack manner b. Nose tip superiorly g. Chin is receded f. Increased incidence of caries 14 . Pigeon chest c. Lips held wide apart c. leading to V shape and high palatal vault b. Bridge of the nose is flat 4. Lack tone of oral musculature d. Adenoid facies : Long. Blood gas constituents: 20% more CO2 and less O2 3. Turbinates become swollen and engorged f. Narrowed maxillary sinus and nasal cavity e. Dental and skeletal a. Dry oropharynx and low grade esophagitis d. narrow face with narrow nose and nasal passage Flaccid lips with upper lip being short Dolicofacial skeletal patterns Expressionless Buccal segment of the maxilla collapsed. Speech acquires a nasal tone g. Low tongue position c.b. d. Examination Mouth breathers Lips will be apart No change in shape or size of external nares 3. Interception of the habit 15 . Mirror test/ fog test: 2 surfaced mirror is placed on the patient's upper lip Nasal breathers Lips will be touching Demonstrate good control of alar muscles air condenses on upper side of mirror on the opposite side nasal breather mouth breather b. cotton flutter downwards = nasal breather. Massler’s water holding test: mouth breather can’t retain water for long time c. Removal of nasal or pharyngeal obstruction by surgery or local medication B. Jwenmen’s butterfly test: few fibers of cotton place just below the nasal opening . upward= mouth breather. Treating the etiological factors 2. Cephalometrics Treatment A. Chronic keratinized marginal gingivitis Diagnosis 1. Mucous and plaque become more tenacious e. Rhinometry ( inductive plethysmography) e. on exhalation. Clinical test a. History 2.d. Elimination of the cause 1. aggression 3. rage. ENT examination Bruxism Definitions 1. According to Vanderas((1995): Non functional movement of mandible with or without an audible sound occurring during day or night Types 1. Occlusal discrepancies 16 . grinding. age 5 – 9 yrs: monobloc activator 3. 2. Daytime or diurnal: It is conscious or subconscious grinding of teeth usually during the day. By rhythmic pattern of EMG activity Etiology 1.cerebral palsy. Exercises: a. Physical exercises: deep breathing exercises in the morning and night b. Class II division I dentition without crowding. Maxillothorax myotherapy 2. mental retardation 2. According to Ranifjord(1966): Bruxism is habitual grinding of teeth when individual is not chewing or swallowing. 2. Psychological factors. 3. Oral screen C. Lip exercises: extend the upper lip as far as possible to cover the vermillion border under and behind the maxillary incisors. Correction of malocclusion 1. hate. 15 – 30 min for 4 – 5 months c. According to Rubina(1986): Bruxism is the term used to indicate non functional contact of teeth which may include clenching. Night time or nocturnal: It is subconscious grinding of teeth char. Age of the patient 2.anxiety. CNS. gnashing and tapping of teeth.1. Class III malocclusion: interceptive methods as chin cap. Treatment consideration 1. Class I skeletal and dental occlusion and anterior spacing: oral shield appliance 2. Hypertrophy of masseter uni/bilaterally 5. Systemic factors. Age of the patient assc with the duration of the habit 2. Crepitation and clicking within the joint c. Grinding/ tapping sounds b. Factors: a. Atypical wear facets ( shinny uneven occlusal wear with sharp edges) 4. Occupational factors Clinical Features 1. Genetics 5. TMJ disorders a. Headache 7. Increase tooth sensitivity ( cold) from excessive abrasion of the enamel c. Tooth mobility ( more in the morning due to bruxing activities during sleep) b. Occlusal trauma: a.4. Non – functional occlusal wear b. Allergies 6. Tenderness of jaw muscles ( masseter n)and lateral pterygoid) b. The molar teeth. Restriction of mandibular movements and jaw deviations (frequently to left) 6. Intensity with which the patient is bruxing c. Muscular fatigue during waking up c. Spread of gingivitis into deeper PD structures and alveolar bone loss 3. Soft tissue trauma c. Occlusal adjustment : 17 . Others signs and symptoms: a. Treatment 1. TMJ disturbances and pain ( dull and unilateral) b. Small ulcerations or ridging on the buccal mucosa opp. Muscular tenderness: a. Tooth structure: a.magnesium deficiency 7. Frequency of bruxing b. Prematurities/ occlusal interferences in restoration should be corrected b. Emotional stress: increase the intensity and duration of lip sucking 18 . Drugs: a. Acupuncture technique for muscles relaxation 11. Wetting the lips with tongue 2.a. Pulling lips into mouth between the teeth Etiology 1. Habits like thumb/ digit sucking 3. Electrical method: electro galvanic stimulation for muscle relaxation 10. Restorative treatment: pulp therapy with full coverage stainless steel crown 4. Biofeedback 9. Orthodontic correction Lip Habit Definition Habits that involve manipulation of lips and perioral structures Classification 1. Relaxation training 6. Occlusal splints: Vulcanite splints cover the occlusal surfaces of all the teeth 3. Muscle relaxants f. Physical therapy 7. LA into TMJ/ muscles c. Sedatives e. Psychotherapy: counseling to decrease in tension/ create habit awareness 5. Vapo coolant ( ethyl chloride for pain within the TMJ) b. Malocclusion 2. Tranquilizers d. Placebos 8. Coronoplasty 2. Class I malocclusion with increased overjet : fixed/ removable appliance to tip the teeth back 2. Lip – reddened. preventing it from cushioning to the lingual of the maxillary incisor during posture and function 19 . Protrusion of maxillary incisors and retrusion of mandibular incisors 2. Labial shield keeps the wire away from lower incisors. Class II: activator to reposition the maxilla to the mandible in favorable position B. Lip bumper: a. Mentolabial sulcus accentuated 4. Lip trap 6. foxed and removable appliances c. Treating the primary habit 1.Clinical Features 1. Positioned in the vestibule of the mandibular arch and serves to prohibit the lip from exerting excessive force on mandibular incisors and reposition the lip away from the lingual aspect of the maxillary incisor b. Malocclusion 5. irritated and chapped area below the vermillion border vermillion border relocated father outside the mouth redundant and hypertrophic at rest chronic herpes infection 3. Lip habit and digit sucking corrected using Hawley’s retainer with labial bow C. Can be combined. Correction of malocclusion 1. Appliances therapy 1. 2nd deciduous molars/ permanent 1st molars are banded and buccal tube is soldered to them d. Lower incisor collapse with lingual crowding Treatment A. Oral shield 2. Open bite 3. Tooth malposition in buccal segment Treatment A removable crib may be constructed to break the habit. Clinical Features 1. Management 1. 3. light cotton mittens as reminder 4. Vestibular screen may also be used. 2. Effects on nails: inflammation of nail beds and of nails. Dental effects: crowding. Application of nail polish. Emotional problem: nervous tension. Psychosomatic successor of thumb sucking Effects 1. Treat basic emotional factor causing the habit. insecurity 2. 2. It may injure soft tissue and may cause an open bite or an individual tooth malposition in buccal segment where a persistent cheek biting habit exists. Mild cases need no treatment. retraction and attrition of incisal edges of incisors. Ulcers at the level of occlusion 2.Cheek Biting Definition This is an abnormal habit of keeping or biting cheek muscles in between upper and lower posterior teeth. nagging or threatening 5. Avoid primitive methods like scolding. Nail Biting Etiology 1. Encourage outdoor activities 20 . Biting of fingers. Definition Repetitive acts that result in physical damage to the individual. Functional: a) Type A: a child with a finger nail biting habit is under a treatment for a skin lesion which is superimposed on pre-existing. tongue. Psychotherapy 2. Clinical Features 1. These are the habits in which the patient enjoys deliberately damaging himself. kness. Palliative therapy 3. sadomasochistic and self-mutilating habits. finger. knee and shoulder biting are common 2. It is seen in mentally ill or psychologically disturbed children. b) Type B: these are secondary to other estd. habits. Organic: in Lesch Nyham disease and De Lange’ syndrome in which symptoms such as repetitive lip. Rotation of thumb while thumb sucking can harm the tissues.Self Injurious Habits AKA masochistic. mouth guards 21 . Etiology 1. c) Type C: this type of behavior has a greater psychogenic component and child may resort to various self injurious habits as a form of stress release. Frenum thrusting 3. Insertion of sharp objects into the oral cavity Treatment 1. Mechanotherapy – protective padding. Picking of gingiva 4. shouders 2. 2. Bobby Pin Opening Usually seen in teenage girls wherein opening of bobby pin with anterior incisors is done. If maxillary incisors are slightly spaced apart. we see notched incisors and partially denuded labial enamel. child may lock his labial frenum between these teeth and permit it to remain in this position for hours. Treatment involves stoppage of the habit. Clinically. On constant repetition this may become a habit which may displace the tooth. Treatment 1.Frenum Thrusting It is an example of self injurious habits. Palliative treatment: adjunctive therapy in form of bandage for any oral ulceration will help in healing of wounds and serve as habit reminder. Treatment for self mutilation may also include use of restraints and protective padding. Mechanotherapy: an oral shield will also deter the child from unconscious continuation of habit. 22 .